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headaches Flashcards

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1
Q

how does an intracrainal lesion cause pain

A

Swelling of the brain by stretching or compressing blood vessels or cranial nerves (could be due to a hemorrhage or tumor)

the brain parenchyma itself does not produce pain

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2
Q

Compare primary headaches to secondary headaches

A

primary - no underlying disease process

Secondary - headache is secondary to an underlying disease process

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3
Q

are you more concerned about a primary or secondary headache

A

secondary

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4
Q

A 24 year old female presents for the sudden onset of the “worst headache of her life.” Her neurologic examination is notable for an enlarged and poorly reactive right pupil. What is the most likely diagnosis?

A

Aneurysmal subarachnoid hemorrhage

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5
Q

Split second, unexpected, worst/not previously encountered, LOC, vertigo, vomiting may be associated with

A

Aneurysmal SAH, cerebellar hematoma

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6
Q

fever and skin rash may be associated with

A

Meningitis

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7
Q

immunosuppressed state may be associated with

A

crypto meningitis, toxoplasmosis

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8
Q

Coagulopathy/anticoagulation may be associated with

A

subdural or intradural hematoma

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9
Q

A 28 year old male presents for complaint of visual problems and headaches. He reports the development of a shimmering light in his left visual field that gets bigger over the course of about 30 minutes, followed by a pounding left sided headache lasting several hours, associated with an upset stomach, light and sound sensitivity. What is the treatment of choice?

A

Sumatriptan - Migraine specific drug

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10
Q

what type of headache is associated with a genetic predisposition

A

migraines

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11
Q

what are key features of migraine headaches

A

nausea, vomiting, light sensitivity, often prevents you from working, studying, or doing what you need to do

periodic, usually unilateral and pulsatile

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12
Q

who is mostly likely to present with migraine headaches

A

begin in late childhood to early adult life (menarche to menopause) and decrease as you get older. More common in females

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13
Q

what are some triggers of migraines

A 
Stress 
Lack of sleep
Hunger
Hormonal fluctuations
Foods (+/-)
Alcohol/nitrates
Weather changes
Smokes, scents, fumes
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14
Q

what are the phases of a migraine headache

A

prodrome, aura, pain, postdrome

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15
Q

what is the prodrome phase of migranes

A 
Depression
Irritability
Drowsiness
Fatigue
Yawning
Rhinorrhea/lacrimation
Hunger/thirst
Cravings for chocolate, nuts, bananas (controversy as to cause or effect)
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16
Q

when does the prodrome phase of a migraine occur

A

occurs hours (6) to days (48hrs) before the headache (in 60% of patients)

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17
Q

what is the most common type of aura

A

visual

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18
Q

when does the aura usually occur and how long does it last

A

usually before sometimes during and rarely after and lasts

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19
Q

what is a migraine without an aura called

A

common migraine or migraine without aura

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20
Q

what causes an aura

A

spreading cortical depression

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21
Q

what is it called if a pt has an aura without a headache

A

acephalgic migraine

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22
Q

describe an aura

A

blind spot near center of vision prohibits reading as peripheral, flashing, pulsating bands of light spread out across the visual field.

zig-zaging lights

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23
Q

what types of migraines are not associated with head pain

A 
abdominal migrane
precordial migraine (chest pain)
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24
Q

what symptoms are commonly present during the pain phase of a migraine

A

Photophobia, phonophobia
Nausea/vomiting
Osmophobia, thermophobia

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25
how long does migraine pain last and what is the onset
gradual onset - minutes to hours | duration - hours to days
26
what receptor defect is associated with migraines
gain of function of the NMDA receptor
27
how does the NMDA receptor contribute to migraines
NMDA activation leads to a burst of cerebral activity which is followed by a loss of neuronal activity = cortical depression that slowly advances forward
28
how is the trigeminal nerve involved in migraine progression
Trigeminal nerves wrap around pain sensitive structures, release local neuropeptides, and convey information to the trigeminal nucleus in the brainstem. Which causes the release of vasodilators which act on pain-producing structures. May lead to neurogenic inflammation. creates a feedback loop
29
what is the postdrome associated with a migraine headache
presents for several hours after, consists of mood changes (euphoria, fatigue), impaired concentration, scalp/muscle tenderness
30
what is the first and second line treatment for migraines
NSAIDS followed by triptans
31
what medications should be avoided in patients with migraines
medications with high medication overuse potential (MOH): especially butalbital-containing medications
32
what is the MOA of triptans
agonists of the 5HT(1B/D) receptors - may lead to vasoconstriction
33
when should triptans be avoided
if the patient has or is at risk for ischemic heart disease, uncontrolled hypertension, renal disease, during pregnancy... (vascular risk factors)
34
what are drug interactions of triptams
avoid within 24 hours of ergotamine use and if the patient is on a MAO inhibitor
35
what are side effects of triptan
``` Warm/Hot sensations Tightness Tingling Feelings of heaviness or pressure Occur in nearly any part of the body Most commonly reported in face, limbs, and chest Occur with all 5-HT1B/1D agonists ```
36
what is serotonin syndrome
* Severe leg-predominant rigidity, dysautonomia (diarrhea, excessive lacrimation, hyperactive bowel sounds), and encephalopathy characterized by myoclonus, hyper-reflexia & seizures * Usually within 24hr of med exposure/change
37
what causes serotonin syndrome
Caused by excessive activation of 5-HT1a and 5-HT2 receptors
38
when is serotonin syndrome a concern
when giving a triptan with an antidepressant
39
what is ergotamine used for
migraines (rarely used since introduction of triptans)
40
what are the side effects of ergotamine
very nauseating | causes uterine contractions
41
what is the MOA of ergotamine
potent arterial vasoconstrictor
42
how is ergotamine taken
suppository
43
what is DHE given for
migraines, cluster headaches
44
How is DHE given to patients
IV, SC, and nasal spray forms
45
what are the benefits of DHE
more potent than a triptan and less side effects than ergotamine
46
what are the contraindiactions for ergots (ergotamine and DHE)
Any type of vascular disease (very similar to triptans) should not be used within 24hrs of triptan therapy
47
when should you consider preventative therapy for migraines
1. Incidence of attacks ≥2-3 per month 2. Attacks are severe and impair normal activity 3. Patient is psychologically unable to cope with attacks 4. Optimal abortive therapies have failed or produced serious side effects
48
besides medications what are some other therapies for migraines
``` Avoid triggers Relaxation, biofeedback, acupuncture Physical therapy Dietary/vitamin supplementation Botulinum toxin ```
49
what types of headaches can botulinum toxin be used to treat
chronic migraines only | - approved only after the patient has failed multiple medications and has multiple headache days per month
50
how long is botulinum toxin treatment affective for
becomes affective after 7-10 days and lasts up to 12 weeks
51
A 48 year old male presents for a severe boring pain in the left eye. What duration of symptoms is most consistent with cluster headaches?
> 30 minutes
52
who is most likely to experience cluster headaches
men in their 40s who smoke or use alcohol
53
describe the time course of cluster headaches
* Clusters last 6-12 weeks * clusters Typically occur every year or two (85% episodic, 15% chronic/unremitting) * 1-4 attacks/day lasting 20m to 3hrs * Rapid onset over usually 15-30 minutes (not seconds) * Invariably unilateral (during the cluster but can switch sides in subsequent attacks)
54
what typically triggers a cluster headache
alcohol
55
when are cluster headaches more likely to occur
spring and autumn and during the night
56
which type of headachw can be associated with Can be associated with a partial Horner's & unilateral rhinorrhea
cluster
57
what are acute therapy options for cluster headaches
- Inhaled oxygen 100% by rebreather at 10-15 L/min - Injectable sumatriptan - Nasal spray triptans - Intranasal lidocaine - Intranasal DHE • prednisone
58
what is the most common form of headaches in adults
tension
59
what are the clinical features of tension headaches
- Bilateral pain lasting >30 minutes, usually 4-6 hours - Band-like head pain with a “pressing” or “tightening” quality - Mild-to-moderate intensity - Not aggravated by routine activity - No nausea/vomiting - Phonophobia & photophobia can occur but not both
60
what is the treatment for tension headaches
• Screen for depression and sleep disorders • May be responsive to TCAs (amitriptyline) • Physiotherapy, biofeedback (sleep may be the best treatment)
61
what is trigeminal neuralgia
Paroxysmal attacks of pain lasting from a fraction of a second to two minutes, affecting one or more divisions of the TN usually affects the jaw and are lightning like pains
62
what daily activities can make trigeminal neuralgia worse
talking or eating
63
at what age does trigeminal neuralgia frequently present
60-70 ( very rare before 40) - in younger patients its often due to MS - you should do imaging to look for tumors
64
what is the treatment for trigeminal neuralgia
carbamazepine (first line, definitely effective) | oxcarbazepine - probably effective
65
how does pseudotumor cerebri present
headache with papilledema indicating increased ICP - no mass lesion or enhancement - normal CSF counts - no CVT
66
how do you treat pseudotumor cerebri
actezolamide, toprimate, surgical intervention
67
what is the potential complication of pseudotumor cerebri without treatment
blindness
68
what are the characteristics of exertional headaches
pulsating headache lasts from 5 minutes to 48 hours and occurring during or after physical activity
69
what age group are most likely to experience exertional headaches
younger patients 10-48
70
how do you treat exertional headaches
beta blockers or indomethacin for 3-6 months

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